Forget Breast vs Formula: It’s about support!

Written by Jenny Thomas, MD, MPH, IBCLC, FAAP

In her book Is Breast Best? Taking on the Breastfeeding Experts and the New High Stakes of Motherhood (New York University Press, 2010), Joan Wolf makes some points that resonate with me. I too find myself frustrated when we treat breastfeeding as a magic potion that confers magical properties to both the mother and baby. And I get angry when we tell new mothers “breast is best” and send them out in the world to solve breastfeeding issues on their own without much community support. (I’ll note here that we are making strides in this regard with the Affordable Care Act, the Business Case for Breastfeeding, the IRS decision to allow pre-tax dollars for breast pumps and other programs which, by their very creation and enactment, acknowledge that the community needs to help new mothers. But given book deadlines, the author may not have heard about all the good work that’s being done to remove these booby traps in time for publication.)

My concern is with how she addresses this pressure on the individual breastfeeding mother and lack of community support. And that’s because she heads in a direction we see all too often: the book devalues breastfeeding itself. Wolf concludes that the science supporting breastfeeding as being better than formula feeding is itself problematic and that in the “overwhelming majority of cases, either breastfeeding or formula feeding is a healthy option.”

The author argues that the consensus about the importance of breastfeeding is clear but hyperbolic and the science is sticky. Since randomized controlled studies can not be done to determine what effect breastfeeding may have (since randomizing a child to not breastfeed is unethical) we are left with observational studies. These observational studies can show correlation but not causation and therefore are inherently problematic.

In addition, observational studies showing the benefits of breastfeeding are marred by confounders, the most important of which, Wolf contends, is the inability to distinguish the benefits of breastfeeding itself from “a comprehensive commitment to healthy living that itself is likely to have a positive impact on children’s health.” So might it be, then, that the careful hygiene that a mother who chooses to breastfeed would practice that makes the difference and not the breastmilk itself?

She has no data to support that as a confounder: we do not know, as she suggests, that breastfeeding mothers wash their hands more or keep their children away from large crowds. But it is the theme to which she returns most frequently: the mothering technique of the breastfeeding mother is what counts, not the breastmilk. If mothers who fed formula to their babies just behaved as breastfeeding mothers do, we’d see the same benefits for those children. This can be so, since “science has not shown us how breastmilk works to protect a baby or promote health.” Therefore, without showing the causality between breastmilk and its purported benefits, we can ignore the observational evidence and conclude that breastfeeding has no real benefit to the developing world.

She also questions why feminists haven’t paid attention to the “all encompassing physical and emotional commitment from mothers” that choose to breastfeed, emphasizing the individual personal responsibility involved and the implied need to raise a child in a risk-free environment. She says the book is “an expose of motherhood and the collective fantasy that mothers can and should produce perfect children.” As to this last point, she shares many examples, but no data.

In order to evaluate Wolf’s premise that the science is problematic, we have to understand observational studies. Observational studies help generate or test a hypothesis. In these studies, groups with a certain risk factor are compared to those without the risk factor and then followed prospectively or retrospectively to find out whether or not the outcome of interest (disease, developmental outcome…) occurred.

And there’s the rub. Lactation is not a risk factor. It’s a physiologic process. And it’s hardly incumbent that those proposing to stick with physiology prove why we’d want to do such thing. Lactation is physiologic. It starts during pregnancy and continues after birth, on purpose. The risk factor is whatever is going to interfere with physiology. And if we choose to interfere with physiology, then the research question is not “does breastfeeding provide benefits?” but is “does the intervention cause harm?”

My hope is that the motivation for any book like this would be similar to the motivation we all share: to make sure that infant feeding decisions are informed; to support the mother in attaining her goals for her child; to engage the community to help her along that journey. A mother who has chosen to breastfeed needs our support. Devaluing the process of breastfeeding, attacking the science or the physiology, doesn’t make that decision less important to that mother.

7 Responses to Forget Breast vs Formula: It’s about support!

As a self-proclaimed professional feminist, I’m always offended when people imply that feminists should be all for formula feeding because it’s so liberating. First of all, I found nothing at all liberating about formula feeding. It tied me to bottles and nipples and washing and buying cans of formula that cost lots of money. Breastfeeding liberated me from all of that and allowed me to focus my mothering on my baby, instead of on being a consumer of the formula industry. But more importantly, I believe that a huge focus of the feminist movement is to force society to stop treating women as though their bodies are broken, and implying that formula is just as good as anything our body makes, is just that. To me, it’s just the same as saying that your breasts aren’t pretty enough, so we have these implants that are just as good, or better, than the real thing, so the “feminist” thing to do is to buy them. My body is perfectly capable of making a food superior to anything that I could buy powdered on a shelf, and I know this because it is the biological norm. That is just a fact to me. And remember, I say this even as a mom who DID formula-feed. I have no judgment about the women who must FF or simply wish to, but my feminist self will defend women’s breasts on every occasion.

This book will be a wonderful reference for women who don’t want to breast feed to point to in “justifying” their decision. As far as the science goes, seriously, are we still out on this issue? I thought this was settled several decades ago? And the fact that the author didn’t provide anything new tells me that the book is just an opinion piece. The argument is weak at best (and laughable at worst). And if I was a formula feeding mother I’d be offended. She basically says formula moms are dirty and lazy. I would really love to know the authors true motivation for writing this book, because it clearly wasn’t to improve the lives of women and children.

I think that we need to turn this around. Breast isn’t best, it’s just the norm. It’s not that breastfed babies have higher IQ’s, or get fewer ear infections. These children are just reaching their potential, and are as healthy as they should be, genetically. It’s that babies that are formula fed have lower IQ’s, and get more ear infections (just two examples, of course, many more could be listed). Scientific research shows us that breast milk is ever evolving, changing in composition to respond to the needs of the particular baby. Formula is formula, “one size fits all.” Breastfeeding needs to normalized, and we need to stop talking about how wonderful breast milk is, and start talking about the harm that can be done by formula. In other words, I agree with the post entirely.

Thanks ladies for making all formula feeding mothers feel horrible. When you start giving as much community and emotional support to mothers who can’t breast feed then maybe you’ll have a leg to stand on. As of now you are plainly and simply stating that your children and especially you yourselves are superior to formula feeding mothers…and if you formula feed than oops I guess you get left out of our exclusive club. Please be mindful if what you say. Not all women can breastfeed and it doesn’t meeb that thier bodies are broken and their children are less than.

We are sorry and sad that you have chosen to feel this way. Best for Babes is proud of our information and support for ALL mothers, whether they breastfeed for 2 days, 2 months, 2 years or not at all, as outlined in our Credo, our story on Christina Applegate (who could not breastfeed), our information on best techniques for bottle-feeding, our information on Insufficient Glandular tissue (which is often mis- or under-diagnosed and may mean inability to breastfeed), our calls for support for women who can’t breastfeed, our promotion of donor milk for women who can not or decide not to breastfeed, our calls for insurance coverage of donor milk and formula for breast cancer victims, and our Facebook policy of zero tolerance for judgment or inflammatory comments. There is no statement on our website that supports your accusations, and there is no basis for your attack. As such, we respectfully ask you to change your tone and your message if you wish participate in a productive, constructive dialogue that leads to changes that truly help moms and babies.